Anatomy, Shoulder and Upper Limb, Sternoclavicular Joint


Article Author:
Thomas Epperson


Article Editor:
Matthew Varacallo


Editors In Chief:
Shivajee Nallamothu
Matthew Varacallo
Joshua Tuck


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
1/4/2019 12:41:34 AM

Introduction

The sternoclavicular (SC) joint is a saddle-shaped, synovial joint that serves as the primary skeletal connection between the axial skeleton and the upper limb. 

Structure and Function

The SC joint articulates the clavicle with the manubrium of the sternum and the superior surface of the first costal cartilage. From an anteroposterior axis, the joint is convex. Vertically, the joint is concave. Structurally, the articulating surfaces of the SC joint are separated by a fibrocartilaginous articular disc which has functional mobility in the anteroposterior and vertical axis.[1]

The posterior sternoclavicular ligament provides the primary anteroposterior stabilization of the SC joint. It is a ligament that extends from the posterior aspect of the sternal end of the clavicle to the posterosuperior manubrium. The anterior sternoclavicular ligament also stabilizes the SC joint and prohibits excessive superior displacement. This ligament joins the medial end of the clavicle and the superior anterior edge of the manubrium. Other ligaments contributing to the stability of the SC joint are the interclavicular ligament which facilitates medial traction of both clavicles, and the costoclavicular ligament which mediates bilateral clavicle and anterior first rib stability. The costoclavicular ligament's orientation to the SC joint, anchoring the inferior surface of the sternal end of the clavicle to the first rib, serves as the primary restraint for the SC joint.

The subclavius muscle also functions to provide joint stability. 

The SC joint is one of five articulations that permit fluid movement of the shoulder girdle. Functionally, it is a diarthrodial, multiaxial joint that provides 35 degrees range of motion for movement in the horizontal and coronal planes and 70 degrees range of motion anteroposteriorly. The joint is additionally capable of 45 degrees of rotation along its long axis. Mechanical input from the shoulder girdle influences the movements of the SC joint.

Important anatomical relationships concerning the SC joint are also worth noting. The brachiocephalic trunk, internal jugular vein, and common carotid artery lie posterior to the SC joint. Other mediastinal structures that lie posterior to the clavicle and SC joint are the vagus nerve, phrenic nerve, innominate artery and vein, trachea, and esophagus. The discussion of these structures and their implications in SC joint pathology will come later in this article. 

Blood Supply and Lymphatics

Vascular supply of the SC joint derives from the internal thoracic artery and suprascapular artery. Both arteries are branches of the subclavian artery. 

Nerves

The SC joint itself receives direct supply by the medial supraclavicular nerve (C3-C4) and the nerve to subclavius (C5-C6). It is also worth mentioning nerves involved in the various movements at the joint. 

  • Elevation: accomplished by the levator scapulae, upper trapezius, rhomboid major and minor muscles
    • Innervation: dorsal scapular nerve, C5 ventral ramus, C3-C4 ventral rami
  • Depression: pectoralis minor, lower trapezius, serratus anterior and inferior muscles
    • innervation: medial pectoral nerve, spinal accessory nerve, long thoracic nerve
  • Protraction: pectoralis minor, serratus anterior muscles
    • Innervation: medial pectoral nerve, long thoracic nerve
  • Retraction: middle trapezius, latissimus dorsi, rhomboid major and minor muscles
    • innervation: spinal accessory nerve, thoracodorsal nerve, dorsal scapular nerve
  • Rotation via elevation of the glenoid cavity: upper and lower trapezius, serratus anterior and inferior muscles
    • Innervation: suprascapular nerve, axillary nerve, long thoracic nerve
  • Rotation via depression of the glenoid cavity: levator scapulae, latissimus dorsi, pectoralis minor, rhomboid major and minor muscles
    • Innervation: dorsal scapular nerve, thoracodorsal nerve, medial pectoral nerve, dorsal scapular nerve

Muscles

While no muscles immediately act on the SC joint, it is important to reinforce that the movement of the SC joint primarily depends on the motion of the scapula and the entire shoulder girdle, including the clavicle. Muscles inserting on the clavicle that influence movement of the SC joint are the deltoid, pectoralis major, trapezius, and sternocleidomastoid muscles. Other muscles influencing movement at the SC joint and their respective innervations are in the "muscles" section of this article.

Physiologic Variants

There are not many anatomical or physiological variations concerning the SC joint. However, some patients may have more prominent attachments of the ligaments supporting the SC joint than others, especially the costoclavicular ligament. This should not be viewed as pathological. 

Clinical Significance

Trauma

Traumatic injury to the SC joint is rare, accounting for only 3%-5% of shoulder girdle injuries. [2] Given the strong stability and reinforcement of the joint, a significant force or a specific vector is often required to damage its structural and functional integrity, such as a motor vehicle collision or a direct blow from a contact sport or fall. Often, an indirect blow to the shoulder is the cause of a trauma that damages the SC joint. Direct blows to the medial clavicle are also frequent. Such blunt force trauma, if strong enough to disrupt the joint space, will lead to SC joint dislocation. Patients with direct trauma to the SC joint will often present with pain localizable to the joint itself. They may complain of shoulder pain or pain in the anterior chest. Often, the patient will have a prior history of trauma, but this is not always the case, as some SC joint injuries may be insidious in presentation. Physical exam may likely reveal swelling, bony prominence of the sternum or clavicle, pain and tenderness, ecchymosis, etc., in addition to severe pain and reduced range of motion of the shoulder joint. 

  • Dislocation: 1%-3% of all dislocations. Depending on the direction of the injuring force, SC joint dislocations can either be anterior or posterior in orientation. 
    • Anterior dislocations result from blows in an anterolateral direction. They are more common than posterior dislocations. 
    • Posterior dislocations are the result of blows in a posterolateral direction. Posterior SC joint dislocations put mediastinal structures at risk. The physician should note any sign of dysphagia, stridor, dyspnea, paresthesia, diminished extremity pulses or cyanosis. Potential complications of posterior SC joint dislocations include pneumothorax, brachial plexus injury and vascular injury, dysphagia, and hoarseness.[3][4][5][6] 
  • Sprain: no joint laxity or instability.
  • Subluxation: tearing of sternoclavicular ligaments, but costoclavicular ligaments intact.

SC joint injuries are classified on the following basis depending on the extent of injury[2]

  • Type 1: SC joint sprain without laxity or pain 
  • Type 2: SC joint ligaments rupture, costoclavicular ligaments intact. Subluxation
  • Type 3: SC joint ligaments and costoclavicular ligaments ruptured, dislocation of joint

Treatment of SC joint injuries is conservative if atraumatic. In anterior dislocations, conservative management is the recommendation. Acute posterior dislocations without evidence of mediastinal injury require management with closed reduction. However, if there are signs of mediastinal injury, emergent open reduction and internal fixation are warranted. 

Osteoarthritis

Osteoarthritis, a condition seen predominately in patients over 60 years of age, is relatively common in the SC joint, with one study showing a prevalence of 89% in patients above 50.[7] Pain associated with osteoarthritis is produced by forward flexion or abduction of the arm. Radiographically, osteoarthritis shows features such as subchondral cysts, joint space narrowing, osteophytes, and subchondral sclerosis.[8] Treatment is primarily conservative. 

Infection

Infection of the SC joint is rare and presents insidiously with a low-grade fever, erythema, mild shoulder discomfort, and joint swelling. The primary organisms responsible for infection of the SC joint are Staphylococcus aureus and Pseudomonas aeruginosa. Diagnosis involves arthrocentesis and MRI to assess joint integrity. Treatment is surgical debridement, en bloc resection, and antibiotic therapy.[9] 

Gout

While uncommon, gout is known to affect the SC joint. Joint aspirate will reveal negatively birefringent crystals under polarized light. 

Rheumatoid Arthritis

In patients with rheumatoid arthritis, especially females, involvement of the SC joint is common.[10] 

Seronegative Spondyloarthropathies

Conditions including psoriatic arthritis, ankylosing spondylitis, and reactive arthritis, notably seen in patients who are HLA-B27 positive, are associated with involvement of the SC joint. SC joint involvement is much more common in psoriatic arthritis, with an incidence of 90% in severe cases. Treatment of these conditions revolves around non-steroidal anti-inflammatory drugs (NSAIDs) and disease-modifying agents.[11]

Synovitis-Acne-Pustulosis-Hyperostosis-Osteitis (SAPHO) Syndrome

In patients with SAPHO syndrome, the SC joint is the most common location of skeletal involvement. Radiographic imaging of the SC joint in patients with SAPHO syndrome will show evidence of inflammatory hyperostosis on CT scan and a "bull's horn" appearance on a bone scan. Treatment of this condition is primarily using NSAIDs, steroids, bisphosphonates, and sulfasalazine.[12] 

Condensing Osteitis

Condensing osteitis is a rare condition that presents with a painful and swollen SC joint. Abduction of the arm may exacerbate the pain. Radiographic evaluation reveals sclerosis of the inferomedial end of the clavicle without signs of bone damage. Histological examination of affected bone reveals reinforcement of cancellous bone and destruction of marrow spaces, and radionucleotide scanning will show increased uptake. NSAIDs are the mainstay of treatment.[13]

Friedrich's Disease

Friedrich's disease, the name given to the avascular necrosis of the medial clavicular end, can present similarly to condensing osteitis. A key differentiating factor between the two conditions is the duration of symptoms. Friedrich's disease presents typically with a shorter duration of clinical symptoms. Additionally, Friedrich's disease is predominantly seen in the adolescent and pediatric patient population. Histological examination of bone in a patient with this disease will reveal bone necrosis, marrow and Haversian canal fibrosis with empty lacunae. Like condensing osteitis, treatment is with NSAIDs.[13]

Other Issues

Imaging Considerations

The SC joint is best imaged utilizing computed tomography (CT) scanning for three-dimensional analysis. Magnetic resonance imaging (MRI) may also be used to analyze the articulating surfaces, fibrocartilaginous articulate disc, and supporting ligaments of the SC joint. 


  • Image 1898 Not availableImage 1898 Not available
    Contributed by Gray's Anatomy Plates
Attributed To: Contributed by Gray's Anatomy Plates

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Anatomy, Shoulder and Upper Limb, Sternoclavicular Joint - Questions

Take a quiz of the questions on this article.

Take Quiz
A patient with bony ankylosis with a pathological fusion of the bones eliminating all movement of the sternoclavicular joint would be able to perform which of the following movements?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Where is the appendicular skeleton of the upper extremity attached to the axial skeleton?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
An 89-year-old woman presents to her primary care provider for an annual physical. She feels well and notes that her chronic knee and back pain are "pretty much the same" and managed with acetaminophen. Her only concern at today's appointment is a pain to her "sternum." She notes that it has been going on for about 8 months, and is worse with activity, specifically forward flexion or abduction of her arms. She notes that acetaminophen helps the pain. She denies any trauma, chest pain, or dyspnea. Vital signs are T: 37 C, HR 68 bpm, RR 14/min, and BP 140/80 mmHg. The physical exam is notable for mild tenderness at the sternoclavicular joint bilaterally upon manipulation of the shoulder. Radiographic examination is most likely to show what findings?

(Move Mouse on Image to Enlarge)
  • Image 1898 Not availableImage 1898 Not available
    Contributed by Gray's Anatomy Plates
Attributed To: Contributed by Gray's Anatomy Plates



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 34-year-old male presents to the emergency department complaining of severe pain to his sternum. He notes that he was stabbed 4 weeks ago with a knife during a bar fight right around the site of his current pain. He initially thought his wound was improving, but for about 2 weeks has experienced mild redness, swelling, and discomfort around the site of the injury. He states that he has "felt warm" but has not checked his temperature. He has no apparent medical problems and takes no medications. Vital signs are T38.5 C, HR 70 bpm, RR 15/min, and BP 128/83 mmHg. The physical exam is notable for swelling and erythema of the left sternoclavicular joint area. The patient asks what type of structure is infected. Which of the following would best answer his question?

(Move Mouse on Image to Enlarge)
  • Image 1898 Not availableImage 1898 Not available
    Contributed by Gray's Anatomy Plates
Attributed To: Contributed by Gray's Anatomy Plates



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 24-year-old college football player presents to the emergency department following an injury received during football practice. When detailing the injury, the patient states he received a direct blow from a helmet to his sternum and has since had mild pain in the sternoclavicular region. He has no apparent medical problems and takes no medication. Vital signs are T: 37 C, HR 76 bpm, RR 14/min, and BP 120/79 mmHg. The physical exam is notable for mild point tenderness at the right sternoclavicular joint, along with minimal pain with the movement of the shoulder girdle. There is no joint laxity or severe joint pain. What muscle provides the primary muscular stability to the sternoclavicular joint?

(Move Mouse on Image to Enlarge)
  • Image 1898 Not availableImage 1898 Not available
    Contributed by Gray's Anatomy Plates
Attributed To: Contributed by Gray's Anatomy Plates



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Anatomy, Shoulder and Upper Limb, Sternoclavicular Joint - References

References

Kiel J,Kaiser K, Sternoclavicular Joint Injury 2018 Jan;     [PubMed]
Worman LW,Leagus C, Intrathoracic injury following retrosternal dislocation of the clavicle. The Journal of trauma. 1967 May;     [PubMed]
Jain S,Monbaliu D,Thompson JF, Thoracic outlet syndrome caused by chronic retrosternal dislocation of the clavicle. Successful treatment by transaxillary resection of the first rib. The Journal of bone and joint surgery. British volume. 2002 Jan;     [PubMed]
Nakayama E,Tanaka T,Noguchi T,Yasuda J,Terada Y, Tracheal stenosis caused by retrosternal dislocation of the right clavicle. The Annals of thoracic surgery. 2007 Feb;     [PubMed]
Gardner MA,Bidstrup BP, Intrathoracic great vessel injury resulting from blunt chest trauma associated with posterior dislocation of the sternoclavicular joint. The Australian and New Zealand journal of surgery. 1983 Oct;     [PubMed]
Lawrence CR,East B,Rashid A,Tytherleigh-Strong GM, The prevalence of osteoarthritis of the sternoclavicular joint on computed tomography. Journal of shoulder and elbow surgery. 2017 Jan;     [PubMed]
Dobson M,Waldron T, SCJ osteoarthritis: The significance of joint surface location for diagnosis. International journal of paleopathology. 2018 Sep 29;     [PubMed]
Schipper P,Tieu BH, Acute Chest Wall Infections: Surgical Site Infections, Necrotizing Soft Tissue Infections, and Sternoclavicular Joint Infection. Thoracic surgery clinics. 2017 May;     [PubMed]
Nakamura H,Shibata Y,Takeda T, Sternoclavicular Joint Swelling in a Patient with Rheumatoid Arthritis. The Journal of rheumatology. 2016 Nov;     [PubMed]
Henriques CC,Sousa M,Panarra A,Riso N, The dark side of SAPHO syndrome. BMJ case reports. 2011 Dec 21;     [PubMed]
Emery RJ,Ho EK,Leong JC, The shoulder girdle in ankylosing spondylitis. The Journal of bone and joint surgery. American volume. 1991 Dec;     [PubMed]
Greenspan A,Gerscovich E,Szabo RM,Matthews JG 2nd, Condensing osteitis of the clavicle: a rare but frequently misdiagnosed condition. AJR. American journal of roentgenology. 1991 May;     [PubMed]
Cowan PT,Varacallo M, Anatomy, Back, Scapula . 2018 Jan     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-Orthopaedic. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-Orthopaedic, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-Orthopaedic, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-Orthopaedic. When it is time for the Surgery-Orthopaedic board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-Orthopaedic.